Careplan For Cholangitis 1w38
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MEDGAR EVERS COLLEGE CITY UNIVERSITY OF NEW YORK SCHOOL OF SCI ENCE, HEALTH AND TECHNOLOGY DEPARTMENT OF NURSING AAS/PN
Student: Lothiare Germain
Date:
Patient Initials: LJM
Diagnosis:
Vital Signs:
BP: 116/72
T: 99.4 F P: 87
R: 18
N# 1 2 3 4 56 7 8 9 10
WEIGHT: HEIGHT:
Pain Score:
AGE: 59
Medication(s):Exonaxaprin 30mg inj SQ, Docusate sod 100mg PO BID, Lidocane HCL 10ml mouth rinse INTRAVENOUS: Dextrose 5% ½ NS 83 ml/hr
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
Pt 59 y/o c/o vague non-radiating pain in RUQ, LJM had previous issions for same symptoms with intermittent ABD distress. Pt also has intermittent fevers and has a temperature of 99.4 F at present. ABD is soft nondistended with bowel sounds heard during auscultation. Pt has poor oral intake with associated weight loss of 15 lbs. pt. denies N/V. Pt has jaundice, with scleral icterus. Pt urine output is dark yellow due to inadequate fluid intake.
Pain related to inflamed bile ducts associated with biliary tract disease AEB fever, yellow sclera and RUQ ABD pain.
Patient will report a reduction an ABD pain associated with cholangitis within 5 days of continued treatment.
Prep pt for ER (endoscopic retrograde cholangiopancreatography )
Pt verbalizes an understanding for procedure
Endoscopic visualization of common bile, pancreatic and hepatic duct for obstruction, tumors, bile duct strictures or injury
Obtain consent for procedure and address any concerns pt may have. ister medications for pain as ordered. NPO for 4 hours before procedure. Assess allergies to iodine or seafood.
Iodine contrast is used for enhanced visualization of
Order for stat and PRN pain medications
structure.
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
59 year old male itted to med surg unit with complaints of ABD pain o RUQ for 4 weeks. Bowel sounds are hear over all four quadrants. Pt sts he moves his bowels infrequently and has difficulty, stating he has episodes of straining to stools. Pt sts his bowel movements are yellow in color. Pt has lost 15 lbs. within one month’s time and has intermittent fevers.
Impaired bowel elimination R/t inflammatory bowel disease AEB: Hard stools; painful defecation.
The patient will report an increase in frequency of stools, with a return of normal consistency within 3 days of treatment.
Asses for causal factors such as fever, emotional strain, abdominal pain, physical exertion, bloody stools, and cramping.
An assessment of medication profile reveal no drugs that would exacerbate gastrointestinal side effects.
*helps to understand causative factor and etiology of problem Observe and record stool frequency, characteristics and amount *helps identify and differentiate severity of episode or disease. Increase fluid intake to 2000 to 3000 ml daily
Despite the use of stool softeners the constipation still persists. The patient is encouraged to follow medication regiment Rx by the doctor. Pt diet reflects a high fiber and increased fluid intake to manage bowel movements.
Give stool softeners to aid in bowel movements.
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
Mr. L J-M expresses discouragement with medication (Docusate) he is on and has refused it several times. He requests an enema instead. He is preoccupied with his physical self and is
Ineffective coping related to unpredictable nature of disease process.
The patient will verbalize an understanding of his disease process and possible complication upon discharge. The pt will also verbalize an understanding of his therapeutic regimen.
Determine both the patient’s and his significant others understanding and methods of dealing with the disease process.
Pt has a better understanding of the need to continue medication regiment and allowing the drugs to work.
*this enables the
Pt understands that talking with staff and
chronically worried ing the bathroom.
nurse to deal more effectively with the current problems. Anxiety may interfere with patient teaching. Help patient identify his own effective coping skills.
family about his fears promotes better coping.
Student: Lothiare Germain
Date:
Patient Initials: LJM
Diagnosis:
Vital Signs:
BP: 116/72
T: 99.4 F P: 87
R: 18
N# 1 2 3 4 56 7 8 9 10
WEIGHT: HEIGHT:
Pain Score:
AGE: 59
Medication(s):Exonaxaprin 30mg inj SQ, Docusate sod 100mg PO BID, Lidocane HCL 10ml mouth rinse INTRAVENOUS: Dextrose 5% ½ NS 83 ml/hr
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
Pt 59 y/o c/o vague non-radiating pain in RUQ, LJM had previous issions for same symptoms with intermittent ABD distress. Pt also has intermittent fevers and has a temperature of 99.4 F at present. ABD is soft nondistended with bowel sounds heard during auscultation. Pt has poor oral intake with associated weight loss of 15 lbs. pt. denies N/V. Pt has jaundice, with scleral icterus. Pt urine output is dark yellow due to inadequate fluid intake.
Pain related to inflamed bile ducts associated with biliary tract disease AEB fever, yellow sclera and RUQ ABD pain.
Patient will report a reduction an ABD pain associated with cholangitis within 5 days of continued treatment.
Prep pt for ER (endoscopic retrograde cholangiopancreatography )
Pt verbalizes an understanding for procedure
Endoscopic visualization of common bile, pancreatic and hepatic duct for obstruction, tumors, bile duct strictures or injury
Obtain consent for procedure and address any concerns pt may have. ister medications for pain as ordered. NPO for 4 hours before procedure. Assess allergies to iodine or seafood.
Iodine contrast is used for enhanced visualization of
Order for stat and PRN pain medications
structure.
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
59 year old male itted to med surg unit with complaints of ABD pain o RUQ for 4 weeks. Bowel sounds are hear over all four quadrants. Pt sts he moves his bowels infrequently and has difficulty, stating he has episodes of straining to stools. Pt sts his bowel movements are yellow in color. Pt has lost 15 lbs. within one month’s time and has intermittent fevers.
Impaired bowel elimination R/t inflammatory bowel disease AEB: Hard stools; painful defecation.
The patient will report an increase in frequency of stools, with a return of normal consistency within 3 days of treatment.
Asses for causal factors such as fever, emotional strain, abdominal pain, physical exertion, bloody stools, and cramping.
An assessment of medication profile reveal no drugs that would exacerbate gastrointestinal side effects.
*helps to understand causative factor and etiology of problem Observe and record stool frequency, characteristics and amount *helps identify and differentiate severity of episode or disease. Increase fluid intake to 2000 to 3000 ml daily
Despite the use of stool softeners the constipation still persists. The patient is encouraged to follow medication regiment Rx by the doctor. Pt diet reflects a high fiber and increased fluid intake to manage bowel movements.
Give stool softeners to aid in bowel movements.
ASSESSMENT
NURSING DIAGNOSIS
PLAN/Expected Outcome
IMPLEMENTATION with rationale
EVALUATION
Mr. L J-M expresses discouragement with medication (Docusate) he is on and has refused it several times. He requests an enema instead. He is preoccupied with his physical self and is
Ineffective coping related to unpredictable nature of disease process.
The patient will verbalize an understanding of his disease process and possible complication upon discharge. The pt will also verbalize an understanding of his therapeutic regimen.
Determine both the patient’s and his significant others understanding and methods of dealing with the disease process.
Pt has a better understanding of the need to continue medication regiment and allowing the drugs to work.
*this enables the
Pt understands that talking with staff and
chronically worried ing the bathroom.
nurse to deal more effectively with the current problems. Anxiety may interfere with patient teaching. Help patient identify his own effective coping skills.
family about his fears promotes better coping.
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